Recertification for interventional cardiology: "Niggling" and complex, or surprisingly instructive?

April 27, 2010

New York, NY - This year and last mark the first years that interventional cardiologists in the US have had to grapple with the issue of recertification, and many are finding there is much more to the process than just sitting for an exam. Some say recertifying is too complex and time-consuming and that the processes involved are not transparent, providing doctors with little feedback as to how they fared. Others are questioning whether there is any evidence that recertification actually improves patient care.

In the US, certification and recertification are not mandatory—the minimum requirements to practice medicine are the issuing of a medical license by each US state. But certification by a specialty board is required by many institutions and is seen as a marker that a physician has met a certain standard, as well as a way for them to demonstrate their knowledge in a particular specialty, subspecialty, or both.

Experts who spoke with heart wire say that the process is causing so many headaches on top of already-busy schedules that some interventionalists have decided it's simply not worthwhile to get recertified at all.

Dr Gregg Stone

"It's been surprising to many people that the requirements for recertification are so much more complex than the initial certification," says Dr Gregg Stone (Columbia University, New York, NY). "In general, once you are initially certified you've proven that you are qualified and it's just a matter of proving that you have kept up. But I've heard many people say they are perplexed by the American Board of Internal Medicine's [ABIM's] direction to make it so confusing and difficult and that they are not going to bother to recertify, even though in general they agree with the concept."

I've heard many people say they are perplexed by ABIM's direction to make [recertification] so confusing and difficult and that they are not going to bother to recertify.

And Dr Larry Dean (University of Washington Medicine Regional Heart Center, Seattle), the president-elect of the Society for Cardiovascular Angiography and Interventions (SCAI), who is himself due to recertify this fall, says: "While I fully support recertification from the standpoint of SCAI—being up-to-date and having that knowledge base refreshed every several years is a good thing—my biggest concern is trying to recertify when I am busy to begin with. The exam is one thing, but they've added all these modules (known as maintenance-of-certification [MOC] requirements), which take additional time but are required in order to take the test. A lot of people are not going to realize until it's too late—there's a fair amount of work required to do these, and you have to knuckle down or you won't be able to sit for the test."

Dr Larry Dean

Dean says that as a consequence he is hearing much the same thing as Stone: "A lot of people are making conscious decisions not to recertify. A lot of my colleagues are in their mid-to-late 50s, and they are saying, 'Recertification is not required for me to be credentialed, so I'm just not going to do it.' "

Recognizing the perceived barriers, the American College of Cardiology (ACC), SCAI, and Transcatheter Cardiovascular Therapeutics (TCT) have all tried to help by offering courses geared toward recertification at their annual meetings.

The older ones, who . . . are qualified for life as general cardiologists . . . are astonished by the need to recertify in interventional cardiology.

Dr George Dangas (Columbia University, New York), who is currently serving as the cochair of the ACC Interventional Cardiology (ACC-i2) symposium and is a trustee for SCAI and codirector of the TCT symposium, says: "There are people bringing up this futility thing. It's not a clear necessity to be board-certified, it's not an absolute requirement by any payer, but a lot of people see it as an investment for the future. What if it becomes a requirement in three years? Then you have to go and do exactly the same thing and you are even more detached. Most people think once you are up for recertification, you should just go ahead and do it and put it behind you. Why take a risk?"

Nevertheless, he points out that a 2009 ACC survey revealed that less than two-thirds of cardiology practices require that their physicians maintain certification in interventional cardiology.

Recertification requirements vary around the world

The regulation of doctors once they have qualified varies among countries. In the UK, recertification is a relatively new concept and is under development for full implementation by 2011, coordinated through the General Medical Council[1]. In Canada, there is no national recertification system; rather, each province determines practice, with some mandating that doctors participate in MOC programs to retain licensure.

In the US, since 1990 doctors who choose to certify after training must regularly recertify. General cardiologists certify in cardiovascular disease and are required to recertify every 10 years, and there are three further cardiology subspecialties—clinical cardiac electrophysiology, advanced heart failure and transplant cardiology, and interventional cardiology—for which candidates must also be first certified in cardiovascular disease. Cardiology is overseen by the ABIM, one of around 20 boards under the umbrella of the American Board of Medical Specialties.

Older cardiologists being caught unaware

The issue of recertification is only just rearing its head for interventional cardiology, because 1999 was the first year of the board certification exam in this subject. So the first wave of interventionalists was required to recertify last year, and many are in still in the process of doing so this year. And while many younger doctors have already recertified in cardiovascular disease earlier in the decade, some older interventionalists are being caught unaware, notes Dangas.

"The older ones—who have not had to recertify in cardiovascular disease because they were lucky enough to qualify before the board requirement came in for that [pre-1990] and so are qualified for life as general cardiologists—have been completely taken by surprise by this. They are astonished by the need to recertify in interventional cardiology. They have no clue what this means, and they are shocked," Dangas says.

Dr George Dangas

And even those interventionalists who knew that recertification was on the horizon are often stunned by the workload involved, he admits. "This is the first time that interventional cardiologists have had to recertify, and everybody presumes it's only an exam; they forget all of these other things, and all of a sudden, if they have postponed what they thought was only an exam to the last minute and then the landslide of 20 things comes on them, it's like, 'Wow, how am I going to get this done in three months?' That's when it becomes stressful."

As well as taking the exam, doctors have a number of other modules to complete, and—unique to the subspecialty of interventional cardiology—they must log a minimum number of procedures over the preceding two years.

Recertification "more complicated" than original certification

Stone says the key issue in his mind is that recertification appears more complicated than the original qualification: "I think the concept of recertification to ensure that a practitioner has stayed up to date with the latest advances 10 years after they first took the exam is laudable, but I disagree with the complexity of the current exam; it should be simpler than the first exam, not more difficult."

Dr Jeff Marshall

But Dr Jeff Marshall (North East Georgia Heart Center, Atlanta, GA), who recertified in interventional cardiology last year, told heart wire : "The process is perceived as cumbersome because it's something most of us have never done before. But overall, once you understand the process—MOC modules, tasks you have to complete—it's quite educational. It's dealing with the unknown that is the hardest part."

Marshall, who helped out with some of the workshops that SCAI hosted at its meeting last year to help members prepare for recertification, argues that if doctors approach recertification with the right attitude, they will be surprised at how much they get out of the process.

"The goal is to have continuous learning, and that is a laudable goal. The things I personally did, some of these MOC modules on the computer and doing some of the live courses at the SCAI meeting, I learned things that made me rethink."

Once you understand the process . . . it's quite educational. It's dealing with the unknown that is the hardest part.

The first step in the MOC program for interventional cardiologists is for doctors to fulfill the procedural requirements, verifying their performance as a primary operator, co-operator, or supervisor of 150 PCI cases in the two years prior to expiration of their certificate.

Dangas explains that "this can create a secondary anxiety, because some people are below that number." But there are other options, he stresses. If doctors have not reached the required 150 cases in the past two years they can instead provide a detailed procedural log of 25 consecutive cases, including outcomes, in which they have served as the primary operator.

"Another way people can make the requirement is just by delaying recertification for another six months or so and try to do more cases during these months and then they will make the numbers," he explains.

Purpose of modules is not "to torture" but to promote interaction

The next stage of recertification is self-evaluation, and this requires that a total of 100 points be obtained from two categories: medical knowledge and practice improvement; the total points can be accumulated at any time throughout the 10-year recertification cycle, something that a lot of people don't realize, says Dangas. Also, if someone is due to recertify in both cardiovascular disease and interventional cardiology around the same time, then the same 100 points will serve both purposes, and the only "extra" step will be the additional examination and the procedural requirements for interventional cardiology, he notes.

The medical-knowledge modules provide updates highlighting recent clinically relevant developments in interventional cardiology; they are available online and can also be done in simulators. Advice and help completing these components and simulator sessions have been particularly popular at recent ACC, SCAI, and TCT meetings, says Dangas. "I suspect [meeting courses] will continue to be sold out throughout this year," he observes.

All these board review and recertification courses are very, very, popular at meetings.

The courses designed by the ABIM and provided at the society meetings combine expert instruction with an interactive audience response system.

"At the end of the session, pretty much everyone knows the correct answers, so the only thing remains is to just go home and put them into your computer," says Dangas.

"The purpose of these modules is not to torture people and make them specifically do it by themselves, it's to stimulate interaction."

However, Dean, who is due to recertify this fall and has already completed a simulator session at a conference, was less impressed with this process in particular. The simulations "mainly have to do with the management of intraprocedural complications, and you have a certain amount of time," he says, "which I think is great. But then I did four or five cases, and at the end just got this thing back saying, 'You did it, thank you, you passed.' They didn't tell me what percentile I was in, and they didn't give me any kind of feedback. I found that pretty unsophisticated, to be honest with you."

They didn't give me any kind of feedback [on simulation]. I found that pretty unsophisticated, to be honest.

Dean also says that some of the bureaucracy involved with the boards is frustrating: "At the moment I am involved in one of these MOC modules: it takes a while, and then you get distracted and the next thing you know you have an e-mail from the ABIM saying, 'This is pending,' and you have to go online and say you want to continue the module. I'm not sure why you have to do that: a reminder would be fine, but why do you have to click on a button and say you are still trying to complete it? There are a lot of things like that that are not very helpful."

Practice-improvement modules provoke most anxiety

The ABIM's requirement for doctors to complete a practice-improvement module (PIM) is the most likely to provoke anxiety, said the people heart wire spoke to. Candidates can choose from a range of subjects such as clinical supervision, preventive cardiology, and communication with referring physicians.

Dangas says the PIMs "stem from the realization of the board that medicine has evolved; it's not just the knowledge of material in some books, but how you interface with the healthcare system. You evaluate your own practice in some way and then send it over to them. They identify what the potential deficiencies are in the current system, and you select one or two and try to improve them. Then you collect data again and see how things have changed, and hopefully, you have improved the outcomes you chose to measure."

Dangas himself, who recertified in interventional cardiology in 2007, chose a PIM that involved administering questionnaires to patients and found this the most difficult component to complete.

Dangas says he now advises interventional cardiologists to choose a PIM such as the acute-MI module. This module "is much more directed toward interventionalists and can be done as a group initiative," he explains. "You try to pinpoint ways in which the door-to-balloon time can be reduced. I tell people, you get organized, you pull together; this can be done as a cath-lab-wide initiative, and the board accepts this. Everybody cooperates; the whole group does the same thing. It's not cheating."

This can be done as a cath-lab-wide initiative, and the board accepts this. Everybody cooperates. . . . It's not cheating.

Marshall agrees with Dangas: "The hardest part is the PIM. I did door-to-balloon times and made some changes in the way we activated the ER, and we were able to show some improvements, and actually it wasn't too onerous. But I know other people have sent questionnaires to patients and can't get them back."

Once doctors have completed their procedural requirements, the medical knowledge and simulator modules, and the PIM, they still have to take an exam. Most, however, feel this is the easiest part. "Nobody likes to take exams," says Marshall, "but the exam was relatively reasonable, and for practicing cardiologists it identifies areas where they are weak; it shouldn't cause too much anxiety." Dangas notes that taking the exam has been somewhat simplified by the wide availability of test centers in which it can be done, cutting down on travel times.

Interventional cardiology so fast moving; ABIM chasing its tail

Dangas says he is cognizant of the fact that there is little evidence to date that recertification actually improves patient care, with a 2009 ACC survey of just over 1000 members indicating that 60% of them did not believe participation in MOC yielded additional insights relevant to their practice.

He says the ACC and ABIM are looking at ways to measure the impact of recertification, but acknowledges outcomes research will take time and is probably not going to have an impact on those recertifying in interventional cardiology within the next couple of years.

Dean has another criticism; he points out that interventional cardiology is changing rapidly. "A lot of what these boards do is based on coronary intervention, but we are now going into structural heart disease, percutaneous valve replacement, PFO closure, atrial/septal occluders, and all sorts of devices that have been developed since the original concept of interventional cardiology and what it entailed. I think this process, as well as the test, will have to change to reflect what current practice is right now.

"I think the ABIM needs to step back a little and reexamine all of that, with the help of the people who are out in the academic and teaching world to make this thing more reflective of what is really going on," he adds.

Stone agrees. And while he says there are many other, more pressing issues occupying the minds of US interventionalists today, such as healthcare reform, recertification remains "a niggling concern for people who want to do the right thing," he says.

And in this case, he is speaking from experience. A search of the ABIM website reveals that while he is grandfathered in cardiovascular disease (having first gotten his certification prior to 1990 for this more general category), his certificate in interventional cardiology expired as of December 2009. Stone told heart wire he is currently considering whether to recertify.


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